Pulsed field ablation (PFA) uses high-intensity electric fields to create myocardial lesions and may potentially interact with cardiac implantable electronic devices (CIEDs). This multicenter study evaluated the effects of different PFA technologies on electrical integrity and device-related complications in patients undergoing left- and right-sided atrial ablation. Consecutive patients with CIEDs undergoing catheter ablation with 4 PFA technologies were included. CIED interrogation was performed at baseline, after ablation, and at ≥ 3-month follow-up. Study endpoints were electrical integrity, defined as changes in sensing, pacing threshold, or impedance, and clinically relevant PFA-related CIED malfunction. Real-time device monitoring was performed in a subgroup to assess electromagnetic interference (EMI). A total of 157 patients were included. PFA was performed using a pentaspline catheter in 110 patients, a lattice-tip catheter in 26, a variable-loop circular catheter in 16, and a circular array catheter in 5. No significant changes in lead parameters were observed immediately after ablation or at 3-month follow-up, including in patients undergoing right atrial PFA. PFA was frequently associated with EMI-related oversensing (93

As patients increasingly access their own electronic health records, the dense technical language of cardiac magnetic resonance (CMR) reports has become a barrier both to patient comprehension and to decision-making by non-imaging physicians. We evaluated whether ChatGPT-4o can enhance the accessibility of CMR reports and generate clinical recommendations, and we quantified the accuracy, safety, and patient reception of these outputs. We prospectively enrolled 75 consecutive outpatients undergoing CMR at two Italian tertiary centres. Each physician-dictated report was processed with ChatGPT-4o through the web interface to produce a simplified patient-facing explanation and tailored clinical recommendations. Two expert cardiologists rated the correctness and completeness of the simplified reports on 5-point Likert scales, with inter-rater reliability by ICC(2,1). Three additional cardiologists rated the AI-generated recommendations for correctness, completeness, and potential harm after a calibration session using a shared written rubric. Patients completed paired questionnaires comparing the standard and AI-enhanced reports across six domains, analysed with the Wilcoxon signed-rank test. Expert-rated correctness of the simplified reports was 4.63 ± 0.88 and completeness 4.42 ± 1.06, with excellent agreement (ICC 0.95–0.99). Patients rated AI-enhanced reports significantly higher than standard reports across every domain (all p < 0.001), including overall satisfaction (8.87 ± 1.11 vs. 6.56 ± 2.22 on a 10-point scale; +35

Background Achieving durable mitral isthmus (MI) block remains challenging. A novel dual-energy lattice-tip catheter enables delivery of both pulsed field (PF) and radiofrequency (RF) energy, potentially improving lesion quality and clinical outcomes. This study aims to assess the feasibility, acute success, safety, and 1-year outcomes of posterior mitral line (PML) ablation using this novel catheter in a multicenter cohort. Methods Consecutive patients from two European centers undergoing atrial fibrillation ablation with PML using the dual-energy system (PF-only or PF/RF, at operator discretion) were prospectively enrolled. Primary outcomes were acute MI conduction block, periprocedural complications, and arrhythmia-free survival at follow-up. Results Among 102 patients, PML was performed with PF-only in 80.4% and PF/RF in 19.6%. Acute MI block was achieved in 92.2% (91.5% PF-only, 95.0% PF/RF, no statistically significant difference). After a median follow-up of 356 days, 74.5% of patients were free from atrial arrhythmia (65.6% in first-time ablation), and arrhythmia-free survival appeared higher with PF/RF than PF-only (85.0% vs 72.0%), but not statistically different. Two major (ventricular fibrillation and coronary vasospasm) and five minor complications were reported. Nine patients (8.8%) underwent redo procedures. Durable MI block was confirmed in two cases, while epicardial gaps accounted for 71.4% of the seven patients with reconduction. Conclusion PML ablation with a dual-energy lattice-tip catheter provided high acute MI block rates, an overall favorable safety profile, and encouraging 1-year outcomes. The potential impact of combined PF/RF energy and epicardial strategies on lesion durability should be evaluated in further randomized studies.

Atrial electrical remodeling spans molecular, electrical, and structural alterations that shorten refractoriness, facilitate reentry, and ultimately create the atrial substrate underlying atrial fibrillation (AF). These changes include ion channel dysfunction, calcium-handling abnormalities, oxidative injury, and deranged proteostasis that are tightly intertwined with atrial fibrosis and cardiomyopathy. High-density mapping and advanced imaging now allow in vivo staging of this substrate: left atrial low-voltage areas and functional conduction phenomena identify regions of fibrosis and conduction slowing that are associated with postablation recurrence, although the benefit of low-voltage area-targeted substrate ablation remains uncertain. Building on this pathophysiological framework, this review integrates experimental and clinical evidence to guide decision making in AF therapy, emphasizing early rhythm-control strategies and careful substrate characterization in sinus rhythm. Pulmonary vein (PV) isolation is presented as the cornerstone of ablation, whereas adjunctive substrate-oriented strategies, including low-voltage modification, hybrid surgical-catheter approaches, and vein of Marshall-based techniques, are discussed as investigational options for selected high-risk patients. Finally, the review contrasts PV- and non-PV-dependent forms of AF and appraises emerging artificial intelligence-guided electrogram interpretation within a mechanism-driven framework for personalized management of atrial electrical remodeling.

BACKGROUND:Although differential pacing (DP) has been conventionally used to confirm the achievement of block across linear lesion sets, high-resolution mapping (HRM)can unmask pseudoblock and persistent residual conduction across the lines. OBJECTIVES:This study aimed to compare conventional DP criteria with HRM for line assessment and to evaluate the impact of persistent residual conduction across a line on the risk of developing atrial tachycardia (AT) during follow-up. METHODS:Our study included consecutive patients who underwent AT or persistent atrial fibrillation ablation with ≥1 atrial linear lesion. We systematically evaluated the existence of a residual conduction through all linear lesions using HRM and compared this strategy with the results of DP. RESULTS:In a cohort of 102 patients, 101 cavotricuspid isthmus lines, 85 roof lines, and 84 mitral isthmus lines were systematically evaluated using DP and HRM. Among the cavotricuspid isthmus lines, 38 lines (37.6%) exhibited residual conduction as determined by HRM. In these 38 cases, DP yielded a false-positive result in 14 cases (37%). For the roof lines, 40 lines (47.1%) showed residual conduction, with DP yielding false-positive results in 16 (40%) of these cases. Regarding the mitral isthmus lines, 24 lines (28.6%) displayed residual conduction, and DP provided false-positive results in 13 (54%) of these cases. The 1-year AT-free survival rate was 95.4% in patients where all attempted lines were successfully blocked, compared to 31.9% in those with ≥1 line that remained unblocked despite multiple ablation attempts. CONCLUSIONS:The systematic use of HRM for line assessment allows to unmask a substantial proportion of pseudoblocks not identified by DP. The existence of a persistent residual conduction through a line is associated with a high risk of AT during follow-up.

Machine learning (ML) algorithms have the potential to enhance the prediction of adverse outcomes in patients with syncope. Recently, gradient boosting (GB) and logistic regression (LR) models have been applied to predict these outcomes following a syncope episode, using the Canadian Syncope Risk Score (CSRS) predictors. This study aims to externally validate these models and compare their performance with novel models. We included all consecutive non-low-risk patients evaluated in the emergency department for syncope between 2015 and 2017 at six Italian hospitals. The GB and LR models were trained and tested using previously validated CSRS predictors. Additionally, recently developed deep learning (TabPFN) and large language models (TabLLM) were validated on the same cohort. The area under the curve (AUC), Matthews correlation coefficient (MCC), and Brier score (BS) were compared for each model. A total of 257 patients were enrolled, with a median age of 71 years. Thirteen percent had adverse outcomes at 30 days. The GB model achieved the best performance, with an AUC of 0.78, an MCC of 0.36, and a BS of 0.42. Significant performance differences were observed compared with the TabPFN model (p < 0.01) and the TabLLM model (p = 0.01). The GB model performed only slightly better than the LR model. The predictive capability of the GB and LR models using CSRS variables was reduced when validated in an external syncope cohort characterized by a higher event rate.

Abstract Background Catheter ablation for atrial fibrillation (AF) has been performed using mainly thermal energy sources (radiofrequency, cryo, or laser). Pulsed field ablation (PFA) is a novel energy with interesting safety and effectiveness demonstrated in previous preclinical and clinical trials. Purpose We sought to assess the electrophysiological characteristics and durability of PFA index procedure procedures using a pentaspline PFA catheter as assessed based on redo procedures in patients with AT/AF recurrences. Methods A total of 169 patients (paroxysmal AF (PAF), 120; persistent AF (PsAF), 49) who underwent PFA using a pentaspline PFA catheter in the index procedure from November 2021 to July 2023 were studied. Pulmonary vein isolation (PVI) was performed with PFA in all patients with additional PFA lines: i)posterolateral mitral isthmus (MI) ablation in 25, ii) posterior line in 40 patients. Twenty-seven patients (PAF, 11; PsAF, 16) had atrial arrhythmia (atrial tachycardia (AT) or AF) recurrence after a 3-month blanking period (16%). We analyzed the electrophysiological characteristics of previous PFA lesions in 18 (PAF, 8; PsAF, 10) out of 27 patients in whom an activation and voltage mapping using 3-D electroanatomical mapping system was available. Results PV reconnections were identified in 7 of 18 patients (13PVs/69PVs ,18.8%) at the PV-LA junctions and carina regions of both left PVs and right PVs, mainly at the anterior aspect of right PV carina (n=6). In 6 out of 10 redo cases, posterolateral MI line using PFA was performed in the index procedure based on our strategy for PsAF ablation. In these 6 cases with previous MI line using PFA for PsAF ablation endocardial PFA was combined with marshall vein ethanolization(Et-VOM). Additional RF endocardial ablation and in the CS was needed to achieve MI block in 2 (33%) in the index procedure. 3D mapping of redo cases showed MI line gaps in 6/6 (100%). In 3 of those patients, the clinical arrhythmia recurrence was a perimitral AT (50%). Nine of the 10 PsAF patients who underwent a redo procedure had an index procedure complete posterior line. Remapping demonstrated durable block in 7/9 (78%). One of these patients presented with a roof dependent AT diagnosed in the redo procedure. Durable posterior lines received a significantly larger number of PFA deliveries during the index procedure: 16.4±3.3 vs 10.0±2.8 respectively, p=0.041). Conclusion This study based on redo cases after PFA using a pentaspline PFA catheter shows that PFA is associated with high durability for PVI and posterior line ablation. However the durability of MI line are poor, even when combined with VOM ethanolization. Further research is needed to define the optimal number of deliveries required to achieve durable posterior line block.

BACKGROUND:With the introduction of pulsed field ablation (PFA) to treat atrial fibrillation (AF), there is interest in studying workflow and sedation strategies to optimize integration into clinical practice. This sub-analysis characterizes early real-world use of general anesthesia versus deep sedation during AF ablation using the pentaspline PFA catheter. METHODS:EU-PORIA is an all-comer AF registry enrolling consecutive patients at seven high-volume centers in Europe. Patients were treated based on institutional standard-of-care. During follow-up, any episode of atrial tachycardia (AT) or AF >30s was considered an arrhythmia recurrence. RESULTS:EU-PORIA enrolled 1233 patients, of which 250 (20%) and 983 (80%) cases were performed using general anesthesia and deep sedation, respectively. Patients treated with general anesthesia were more often male and non-paroxysmal AF. In the general anesthesia group, 72% received pulmonary vein isolation (PVI)-only versus 90% in the deep sedation group (p<0.01), and 3D mapping was used in 60% of general anesthesia and 27% of deep sedation cases (p<0.01). Procedure and fluoroscopy times were shorter with deep sedation (51[36-84] vs 75[60-90] min; 13[8-19] vs 19[15-26] min; p<0.01). There were no differences in the incidence of serious adverse events. At 1-year follow-up, 74.8% and 73.8% of patients in the general anesthesia and deep sedation groups, respectively, were free from recurrent AF/AT (p=0.87). CONCLUSION:AF ablation using deep sedation with the pentaspline PFA catheter demonstrated a safety and efficacy profile consistent with procedures performed under general anesthesia. This characterization of real-world use warrants further evaluation to understand optimal sedation strategies with PFA technologies.

Background: Same-day discharge (SDD) has been adopted for interventional cardiology procedures, however, data on patient experience are scarce. Aims: To investigate patient-reported experience after various SDD electrophysiology procedures. Methods: Consecutive patients undergoing electrophysiology procedures, who fulfilled pre-defined eligibility criteria for SDD, completed the questionnaire before discharge. Procedures suitable for SDD included non/minimally-invasive (e.g. electric cardioversions, tilt tests) and invasive procedures (e.g. cardiac device replacements, catheter ablations). The questionnaire assessed patient experience before and during the procedure, satisfaction with the provided information and understanding of the discharge instructions. Results: The questionnaire was completed by 501 patients (57.5% men). Invasive procedures accounted for 56.7% of SDD procedures. Most patients (88.9%) described SDD as a good or quite good experience, while 95.3% would not hesitate to undergo a second SDD procedure if necessary. A direct interview with a healthcare team member was the preferred method of obtaining information. At discharge, a considerable number of patients were unsure about the provided instructions, including those related to anticoagulation. Patient-reported satisfaction did not differ between invasive and non/minimally invasive procedures (P = 0.06). However, after an invasive procedure, patients had a better understanding of discharge instructions (59.5% vs 41.9%; P < 0.001). Most patients who underwent a procedure under general anaesthesia reported a good or quite good experience (87.7% vs 84.2% of sedation patients; P = 0.16). Conclusion: SDD was generally a positive experience for patients undergoing invasive or non/minimally invasive procedures. However, discharge instructions and patient understanding require improvement. (c) 2024 Elsevier Masson SAS. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

BACKGROUND:Real-life data on efficacy and safety of pulsed-field ablation (PFA) using the pentaspline multi-electrode catheter in symptomatic atrial fibrillation (AF) patients is still scarce. OBJECTIVE:This study aims to assess the efficacy and safety of PFA in patients with persistent AF. METHODS:Data from early commercial use across seven European centers were collected in a registry. To confirm the efficacy and safety of extra pulmonary vein (PV) ablation, patients were categorized into two groups: those undergoing pulmonary vein isolation (PVI) alone and those receiving additional ablation. Procedural and follow-up data were collected. RESULTS:The study included 448 patients (347 PVI only, 101 PVI + α). In the PVI + α group, extra PV ablation included left atrial posterior wall isolation (87%), mitral isthmus ablation (37%), and cavo-tricuspid isthmus ablation (3%). At 1-year follow-up, the PVI only group showed significantly fewer atrial tachyarrhythmia recurrences compared to PVI + α group (69% vs. 56%, p = 0.013). While AF recurrence did not significantly differ (25% vs. 28%, p = 0.713), PVI + α group had a significantly higher atrial tachycardia recurrence (8% vs. 22%, p < 0.001). Major complications occurred in 2.0% versus 1.0% (PVI only vs. PVI + α), including pericardial tamponade (6 vs. 0; p = 0.345) and stroke (1 vs. 1; p = 0.400). CONCLUSIONS:PVI plus extra PV ablation using a pentaspline PFA catheter is associated with a higher incidence of atrial tachycardia recurrences. For persistent AF, a simpler approach of performing only PVI may be more effective.

Aims:Syncope remains a diagnostic challenge despite advancements in testing and treatment. Cardiac syncope is an independent predictor of mortality and can be difficult to distinguish from other causes of transient loss of consciousness (TLOC). This paper explores whether artificial intelligence (AI) can improve the evaluation and management of patients with syncope. Methods and results:We conducted a literature review and incorporated the opinions of experts in the fields of syncope and AI. The cause of TLOC is often unclear, hospitalization criteria are ambiguous, diagnostic tests are frequently non-informative, and assessments are costly. Patients are left with unanswered questions and limited guidance. Artificial intelligence (AI) has the potential to optimize syncope evaluation by processing large data sets, detecting imperceptible patterns, and assisting clinicians. However, AI has limitations, including errors, lack of human empathy, and uncertain clinical utility. Liability issues further complicate its integration. We present three viewpoints: (i) AI is crucial for advancing syncope management; (ii) AI can enhance the patient experience; and (iii) AI in syncope care is inevitable. Conclusion:Artificial intelligence may improve syncope diagnosis and management, particularly through machine learning-based test interpretation and wearable device data. However, it has yet to surpass human clinical judgment in complex decision-making. Current challenges include gaps in understanding syncope mechanisms, AI interpretability, generalizability, and clinical integration. Standardized diagnostic approaches, real-world validation, and curated data sets are essential for progress. Artificial intelligence may enhance efficiency and communication but raises concerns regarding confidentiality, bias, inequities, and legal implications.

Polymorphic ventricular tachycardia (PMVT) is characterized by a typical change in QRS morphology and amplitude. This study aims to evaluate human PMVT mechanisms through in vivo ECG imaging (ECGI) mapping in patients with a normal QTc. All patients from UZ Brussel and CHU Bordeaux were screened. The inclusion criterion for the study was PMVT mapped with ECGI. Exclusion criteria were as follows: (1) long QT, (2) premature ventricular contractions inducing PMVT, and (3) acute ischemia. Phase mapping was performed for each PMVT episode, and rotational and focal activity was adjudicated. A total of five patients were analyzed, and five episodes of PMVT were mapped. PMVT duration was 5.9 s, and the cycle length was 242.4 ms. The mean number of rotational activities was 2.5 ± 1.2, with a mean of 2.9 rotations on the apex. The mean number of focal activities was 1.4 ± 0.9. PMVT mechanism was consistent with the following. In the first phase of PMVT, a stable rotor was found over the ventricular apex. The reduction of QRS amplitude in PMVT was associated with the appearance of a non-apical activity. The further reduction of QRS amplitude (trough or minimum) was secondary to a fusion between the apical wavefront and the non-apical wavefront. In the second phase of PMVT, a stable rotational or focal activity was found. The main mechanism of human PMVT maintenance was rotational activity over the ventricular apex. Changes in QRS morphology and amplitude were secondary to a fusion between apical and non-apical activities. The main mechanism of human polymorphic ventricular tachycardia maintenance is rotational activity over the ventricular apex. Changes in QRS morphology and amplitude are secondary to a fusion between apical and non-apical activities.

BACKGROUND:Brugada syndrome (BrS) is an arrhythmogenic disorder associated with sudden cardiac death primarily owing to ventricular fibrillation (VF). Monomorphic ventricular tachycardias (MVTs) are rarely reported, and little is known about their characteristics. OBJECTIVE:This study aimed to evaluate the characteristics of patients with BrS presenting with MVT compared with those with VF. METHODS:We performed a retrospective multicenter study of patients with BrS who received an implantable cardioverter-defibrillator (ICD). Inclusion criteria were (1) the initiation of ventricular arrhythmia on ICD recordings and (2) the absence of antiarrhythmic drugs or previous ventricular ablation. Arrhythmic events were classified as MVT or polymorphic ventricular tachycardia (PVT)/VF (both referred to as VF) according to the guidelines. We analyzed clinical data, characteristics related to arrhythmia initiation, and electroanatomic substrate. RESULTS:Among 793 patients with BrS with ICDs (44.2 ± 17.7 years, 37.1% women), 54 met the inclusion criteria. ICD recordings showed a total of 47 VF episodes and 27 MVT episodes, overlapping in only 1 patient. Patients with MVT were older at first event (47.7 ± 13.4 vs 40.7 ± 12.6 years, P = .06), had higher QRS duration, more prevalence of syncope, and later recurrences after ICD implantation (median 51 vs 20 months, P = .018). Rapid rhythms (>100 beats/min) were more frequent before MVT than VF (48.1% vs 8.5%, P < .001) with a lower incidence of ectopy (22.2% vs 61.7, P = .001). Abnormal epicardial substrate was broader in patients with MVT in baseline conditions (11.3 ± 5.5 cm2 vs 6.8 ± 3.2 cm2, P = .006). CONCLUSION:VF/PVT and MVT in patients with BrS have distinct clinical presentations. MVT shows a later onset compared with VF/PVT and is associated with a broader substrate area.

Abstract Background Pulsed field ablation (PFA) has emerged as a novel non-thermal energy source for cardiac tissue ablation. A novel focal 9mm lattice tip catheter, namely Sphere-9 (Affera Inc), has recently received regulatory approval; the technology is part of a technology that allows the delivery of either pulsed electric field or radiofrequency energy and incorporates a proprietary 3D electroanatomical mapping system. Purpose To describe the first real-world, multicenter experience with the AfferaTM system. Methods Consecutive AF patients undergoing first-time or redo atrial tachyarrhythmia ablation with the AfferaTM system in two different centres between August and November 2023 were prospectively enrolled. PFA was always used to ablate the posterior left atrium, whereas anterior applications were performed using either radiofrequency energy (RF/PF strategy) or PFA (PF/PF strategy) based on operator's discretion. Data on first-pass pulmonary vein isolation (PVI) and posterior wall isolation (PWI), as well as success rate of extrapulmonary ablation were reported. Primary safety endpoint included any technology-related periprocedural complications. Results 46 patients (mean age: 67±10; 41.3% males, 60.8% non-paroxysmal AF) were included. 5 (10.8%) patients were in atrial flutter (AFlu) at the beginning of the procedure, whereas AF was the rhythm at presentation in 19 (41.3%) others. First-time PVI was performed in 37 (80.4%) patients, 68.4% of whom received concomitant PWI. PVI was performed with PFA-only in 27% of them. First-pass isolation was achieved in 97.3% and 100% of PVI and PWI cases, respectively. Additional lesions included an anterior or posterior mitral line (6 and 15 patients), CTI (4 patients) or substrate ablation in 3 patients. Evidence of first-pass line block was documented in 96.4% of patients. The remaining 9 (19.6%) patients had already undergone a previous ablation; remapping showed 27.7% of PVs requiring reisolation. PWI was performed in 88.9% of them, for the first time (75%) or due to reconnection (25%). Additional lesions included an anterior or posterior mitral line (3 and 3 patients) or CTI in 2 patients. Evidence of first-pass line block was documented in 100% of patients. In 3 AFlu patients, the arrhythmia was mapped and termination was achieved while performing an AML (2 patients) and CTI (1 patient). Procedural duration was 96.5±15.6 min for first time and 97.8±12.6 min for redo procedures. Mean left atrial dwelling and fluoroscopy times were 75.4±17.6 min and 7.36±2.1 min, respectively. No technology-related complications were documented. Conclusions AF ablation with the focal 9-mm lattice tip catheter Sphere-9 confirmed high efficacy and safety in a real-world population.

Differentiation of syncope from transient loss of consciousness can be challenging in the emergency department (ED). Natural Language Processing (NLP) enables the analysis of free text in the electronic medical records (EMR).The present paper aimed to develop a large language models (LLM) for syncope recognition in the ED and proposed a framework for model integration within the clinical workflow.Two models, based on both the Italian and Multilingual Bidirectional Encoder Representations from Transformers (BERT) language model, were developed using consecutive EMRs. The “triage” model was only based on notes contained in the “triage” section of the EMR. The “anamnesis” model added data contained in the “medical history” section. Interpretation and calibration plots were generated.The Italian and Multi BERT models were developed and tested on both 15,098 and 15,222 EMRs, respectively. The triage model had an AUC of 0·95 for the Italian BERT and 0·94 for the Multi BERT. The anamnesis model had an AUC of 0·98 for the Italian BERT and 0·97 for Multi BERT. The LLM identified syncope when not explicitly mentioned in the EMR and also recognized common prodromal symptoms preceding syncope.Both models identified syncope patients in the ED with a high discriminative capability from nurses and doctors’ notes, thus potentially acting as a tool helping physicians to differentiate syncope from others transient loss of consciousness.

Currently, pulmonary vein isolation (PVI) is the gold standard in catheter ablation for atrial fibrillation (AF). However, PVI alone may be insufficient in the management of persistent AF, and complementary methods are being explored. One such method takes an anatomical approach—improving both its success rate and lesion durability may lead to improved treatment outcomes. An additional approach complementary to the anatomical one is also attracting attention, one that focuses on epicardial conduction. This involves ethanol ablation of the vein of Marshall (VOM) and can be very effective in blocking epicardial conduction related to Marshall structure; it is becoming incorporated into standard treatment. However, the pitfall of this “Marshall-PLAN”, a method that combines an anatomical approach with ethanol infusion within the VOM (Et-VOM), is that Et-VOM and other line creations are not always successfully completed. This has led to cases of AF and/or atrial tachycardia (AT) recurrence even after completing this lesion set. Investigating effective adjunctive methods will enable us to complete the lesion set with the aim to lower the rates of recurrence of AF and/or AT in the future.

Abstract Introduction On one hand pulsed-field ablation (PFA) has shown favourable data in terms of safety and efficiency for pulmonary veins isolation (PVI). One the other hand, hybrid ablation results in better outcomes in patients with persistent atrial fibrillation (AF), as it combines a thoracoscopic epicardial and transvenous endocardial approach in a single procedure. Purpose Aim of this study was to to compare 1-year follow-up data of patients with long standing persistent AF undergoing PVI and posterior wall isolation using PFA, and hybrid AF ablation. Methods Consecutive patients with long standing persistent AF undergoing a first PVI with PFA at our institution were included. For comparison, patients with long standing persistent AF undergoing a first PVI with hybrid ablation were selected using a 1:1 nearest neighbor propensity score matching. Hybrid AF ablation was performed in a one-step procedure: (i) thoracoscopic ablation followed by (ii) endocardial mapping and eventual ablation. All patients received PVI and posterior wall isolation in both group. Additional lesions were performed based on clinical indication and physician judgement. The primary endpoint was recurrence of atrial tachyarrhythmia after 12 months of follow-up (with a blanking period of 3 months). Results A total of 130 patients with persistent AF underwent hybrid ablation and 72 patients underwent PFA. 85 patients (age:67.5±9.7 years, 68.2% males, CHA2DS2-VASc: 2.5±1.3) with long standing persistent AF underwent their first AF ablation (PFA N= 39; Hybrid N = 46). After a 1-year follow-up, freedom from atrial tachyarrhythmia recurrence was 74.4% with PFA and 71.7% with hybrid ablation (p = 0.786). After propensity score matching, a total of 39 matched pairs of PFA and hybrid first AF ablation remained. The result remained unchanged and no significant difference was observed between treatment cohorts after matching (Figure 1, p=0.039). Conclusion In a propensity score matched analysis of patients with long standing persistent AF, freedom from any atrial tachyarrhythmia 1 year after AF ablation using PFA was favourable and at least as good as with hybrid ablation.

Clinical decision-making regarding syncope poses challenges, with risk of physician error due to the elusive nature of syncope pathophysiology, diverse presentations, heterogeneity of risk factors, and limited therapeutic options. Artificial intelligence (AI)-based techniques, including machine learning (ML), deep learning (DL), and natural language processing (NLP), can uncover hidden and nonlinear connections among syncope risk factors, disease features, and clinical outcomes. ML, DL, and NLP models can analyze vast amounts of data effectively and assist physicians to help distinguish true syncope from other types of transient loss of consciousness. Additionally, short-term adverse events and length of hospital stay can be predicted by these models. In syncope research, AI-based models shift the focus from causality to correlation analysis between entities. This prompts the search for patterns rather than defining a hypothesis to be tested a priori. Furthermore, education of students, doctors, and health care providers engaged in continuing medical education may benefit from clinical cases of syncope interacting with NLP-based virtual patient simulators. Education may be of benefit to patients. This article explores potential strengths, weaknesses, and proposed solutions associated with utilization of ML and DL in syncope diagnosis and management. Three main topics regarding syncope are addressed: 1) clinical decision-making; 2) clinical research; and 3) education. Within each domain, we question whether “AI will be better than humans,” seeking evidence to support our objective inquiry.

Background Pulsed field ablation (PFA) is selective for the myocardium. However, vagal responses and reversible effects on ganglionated plexi (GP) are observed during pulmonary vein isolation (PVI). Anterior-right GP ablation has been proven to effectively prevent vagal responses during radiofrequency-based PVI. Objective The purpose of this study was to test the hypothesis that PFA-induced transient anterior-right GP modulation when targeting the right superior pulmonary vein (RSPV) before any other pulmonary veins (PVs) may effectively prevent intraprocedural vagal responses. Methods Eighty consecutive paroxysmal atrial fibrillation patients undergoing PVI with PFA were prospectively included. In the first 40 patients, PVI was performed first targeting the left superior pulmonary vein (LSPV-first group). In the last 40 patients, RSPV was targeted first, followed by left PVs and right inferior PV (RSPV-first group). Heart rate (HR) and extracardiac vagal stimulation (ECVS) were evaluated at baseline, during PVI, and postablation to assess GP modulation. Results Vagal responses occurred in 31 patients (78%) in the LSPV-first group and 5 (13%) in the RSPV-first group (P <.001). Temporary pacing was needed in 14 patients (35%) in the LSPV-first group and 3 (8%) in the RSPV-first group (P = .003). RSPV isolation was associated with similar acute HR increase in the 2 groups (13 +/- 11 bpm vs 15 +/- 12 bpm; P = .3). No significant residual changes in HR or ECVS response were documented in both groups at the end of the procedure compared to baseline (all P >.05). Conclusion PVI with PFA frequently induced vagal responses when initiated from the LSPV. Nevertheless, an RSPV-first approach promoted transient HR increase and reduced vagal response occurrence.